Combating drug diversion—what you can do to help

Drug diversion is a problem at every hospital, experts content

Many in healthcare will tell you outright that drug diversion isn’t a big problem in their organization, says Commander John Burke of the Warren County Drug Task Force in Lebanon, OH. “That is people putting their heads in the sand,” he says.

It’s happening everywhere. The question is whether or not you are catching it and trying to stay a step ahead of the diverters.

It’s hard to determine the scope of the problem in hospitals, says Gina Pugliese, RN, MS, vice president of the Premier Safety Institute in Charlotte, NC. “There isn’t a lot of data for the acute care setting,” she explains. But she says there is data showing that between the mid-1990s and the mid-2000s, the number of opioid prescriptions has doubled, that Fentanyl sales have quadrupled, that opioid deaths are up 100%, and that there were some 2 million drug abusers over the age of 12 in 2010. Those bits of data indicate the scope of the problem in the wider community, and what is a hospital but a microcosm of the community in which it exists?

During a webinar on the topic in September, Pugliese asked how many of the 2,000 attendees had investigated a potential drug diversion incident. Only 70% responded yes.

You might view this as a problem for security or law enforcement — or risk management if you have patients who have been adversely affected. But it’s a patient safety issue, too, says Christian Hartman, PharmD, MBA, FSMSO, founder and president of the American Society of Medication Safety Officers, director of clinical quality and patient safety at Wolters Kluwer Health, and a partner at Lucian Metrics in Boston. It impacts patients who don’t get the medication they need because someone is stealing it and patients who are under the care of someone who is an addict and is probably not functioning at his or her best or with the needs of the patient in mind.

Pugliese mentions a case where a drug diverter was pulling meds out of vials and replacing it with a single bag of saline she kept. But that saline was contaminated with bacteria that ended up infecting patients. “They spent so much time ruling out so many other things — the pump, contaminated narcotic from manufacturers, whether the patients had bloodstream infections. Some even went to surgery to find out what was wrong. In retrospect, they found one provider that had a high frequency of accessing the lock box. And the person diverting was close with the people doing the investigation.” It took a long time to untangle.

Build a team, make a plan

Burke says if you have patients who are taking pain medications on an as-needed basis, you probably have drug diverters or people aspiring to divert drugs. And even if you are a lucky organization where this hasn’t occurred, you still need to have a plan for it if it does.

That means putting together a team who will handle all cases of suspected drug diversion. He suggests the head of pharmacy, someone from nursing, a representative from human resources, and perhaps someone from security, depending on the role security plays in your organization. Any time there is a discrepancy in counts or charts, this is the group that will convene and try to figure out if there has been a theft, and if so, what happens next.

“That doesn’t mean that they meet as soon as you find a discrepancy in what you should have,” he says. “Give the nurse manager a time limit to try to resolve it. If he or she can’t do it in a day or two, move it up to the team.”

If you do suspect theft, how do you determine the culprit? Consider the people who have access to the medications, he says. Is anyone exhibiting a change in behavior? That might not mean drugs; it could be a divorce or a problem child. But be aware of it. Look at whether someone is disappearing into the bathroom a lot. Or if a particular nurse has patients who just aren’t doing as well as they should be. Know what the typical charting behavior is of your nurses. “If someone’s charting or reports are suddenly different, or if there is a lot of wastage with someone where there wasn’t before, that is a red flag,” Burke says.

Auditing charts is necessary to keep track of what’s normal and what looks fishy, he continues. Consider doing charts from half the nurses or others who have access to the drugs each month. If someone is on your radar as being suspicious, make sure that employee’s charts are audited regularly until you allay your suspicions or find proof that there is a problem.

Burke says you should talk to the patients who are on PRN medications. Find out if they are doing better or if they are having more pain than they ought. If you suspect a nurse who is dealing with a patient of this kind, ask the patient if he or she recalls asking for medication at the times when the nurse has indicated. Look at nurses who are always short in their counts. If someone has documented that they witnessed wastage, check with that person that any initials or signatures are, indeed, theirs. Taking pills that were supposed to be disposed of is another tried and true method for diverters, he adds.

Pugliese says that you can go deeper and look at your HCAHPS scores and see if pain management is getting the patient satisfaction scores you think it should. If it isn’t, look deeper at some of the adverse events you have related to opioid use. If you are having an unexpected number of patients with pain continuing after medication, you may have a diversion problem.

Increasingly, Burke says, you have to think about not just controlled substances, but other expensive drugs. In an economic recession, when many are struggling, it’s possible that someone will steal some expensive brand-name drug for a family member who can’t afford it. “Know what the expensive drugs are that you keep on the floor,” he says. “Spot check them. It’s not the big issue, but it’s still something to consider.”

While a large, busy facility with a large number of employees might offer better cover for diversion, even small hospitals should be on guard. Rosemary Hargreaves, MHA, BSN, AS, RN, LSSGB, is director for performance improvement and risk management at Shriner’s Hospital in Boston, a 30-bed facility. But she came from Boston City 14 years ago, where they worked hard to develop a comprehensive drug diversion prevention plan, and she took that information with her to her new role.

One of the big lessons she learned was to look at the packaging that drugs come in to see if it makes it harder to steal, or easier. She recalls one medication that came in clear vials with clear stickers. If you looked quickly, you’d think the drug information was printed directly on the glass. But the label was a sticker that could easily be swapped for a sticker from a less high-risk drug. “They could have taken a vial of Demerol and replaced the label with one for saline,” she says.

Cardboard packaging is easier to tamper with than plastic, says Hargreaves. If you have things coming in boxes, look to see if the integrity of that package has been violated. If it’s a significant worry or problem, you can often work with the company to change packaging to make it more impregnable.

She also makes sure that all the employees know that chain of custody is continuously audited. “We include that in orientation,” Hargreaves says. If they know up front that this is something you look at and look at regularly, they may be less willing to take a chance stealing from your facility.

Most important, though, is having the kind of environment where anyone can speak up about suspicions, Hargreaves says. People don’t like to think that a member of their team, with whom they work closely, would do anything to harm a patient. “They will second-guess themselves, especially if it’s a drug that sounds like something less dangerous or looks like something less dangerous.” Employees need to feel comfortable and have a willing and non-punitive person to confide in. If need be, follow in the footsteps of Mayo Clinic, which has an extensive list of best practices related to preventing drug diversion. (For links to a list of some of Mayo’s protocols, see box page 4.)

Spend now to save later

Some of the things you can do to prevent diversion take time and resources, Pugliese says, but they work. These include using two people to confirm all transitions of controlled substances — from pharmacist to lock box, from lock box to patient. Check how many times the lock boxes are being opened, she says. It can tell you if someone is taking peeks to see what’s there but not taking anything out. Try to make things dose-specific, rather than a range of doses, so that all of what is leaving the pharmacy is going into the patient. “Randomly assay waste from units and from pharmacy. Do more blind counting. And do it all with two people.”

Add video cameras in key locations, and put the lock boxes in high-traffic areas, she says. And be sure to push your legislators and regulators to institute centralized databases of diverters so they don’t hop from place to place. “These people aren’t stupid. They are clever. They will quit before your suspicions are too intense. They will create special pockets to conceal syringes to swap out. They will count on the trust of their coworkers who don’t want to believe the worst of them.”

Look, too, at reducing your use of opioids in general. They are often the first thing that is prescribed with certain kinds of patients, says Pugliese.

Hargreaves says to shell out for new technology when it comes out. And pay for good background checks on employees who will have access to the drugs, she adds.

Balking at the cost? A drug diversion case is expensive. “When you think of all the programs you have to implement for patient safety and quality, you don’t balk at other things that reduce harm. This is just another program to reduce harm,” Pugliese says.


For more on this topic contact:

  • Commander John Burke, Warren County Drug Task Force, Lebanon, OH. Email: Telephone: (513) 623-3278.
  • Christian Hartman, PharmD, MBA, FSMSO, President American Society of Medication Safety Officers, Boston, MA. Email:
  • Gina Pugliese, RN MS, Vice President, Safety Institute, Premier Healthcare Alliance, Charlotte, NC. Email:
  • Rosemary Hargreaves, MHA, BSN, AS, RN, LSSGB, Director for Performance Improvement/Risk Management, Patient Care Assessment Coordinator, Meaningful Use Authorized Agent. Shriner’s Hospital, Boston, MA. Email: Telephone: (617) 371-4780.